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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Fibroid removal
Fibroids can be removed from the abdomen by several methods. Small fibroids may be removed directly through
laparoscopic trocars. Larger fibroids can be morcellated using a power morcellator intra-abdominally, within a contained
enclosure,
8
or manually through an extended incision (Video 3.5.2 ). They can also be removed through a posterior
colpotomy incision.
When removing fibroids, smaller ones should be removed first so as to lessen the likelihood of losing track of them around
the bowel. A tally should be kept of the number inside and the number removed to ensure that all fibroids are accounted for.
Care should be taken to ensure that all pieces of myoma are fully removed. It is wise to ensure that all pieces of each
fibroid are removed prior to moving on to the next fibroid.
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Abdominal Myomectomy Technique
Intraoperative technique
A Pfannenstiel incision can often be utilized for uteri of <20 weeks gestational size. The patient should be examined under
anesthesia to determine the mobility of the uterus. A vertical midline incision should be used if the uterus is immobile or
doubt exists as to whether it can be exteriorized through a Pfannenstiel incision.
In most cases, an abdominal retractor is not needed, as the uterus can be exteriorized and allow adequate access to all
fibroids.
Use of a tourniquet around the uterus in addition to vasopressin injections can reduce intraoperative blood loss. A 1-in
Penrose drain is wrapped around the posterior aspect of the uterus. The drain is then tied anteriorly around the lower
uterine segment with a single overhand knot and clamped with a hemostat to keep it from coming loose. Care should be
taken to ensure that the tourniquet is not directly compressing the fallopian tubes. The drain knot should also not be
compressing the bladder.
The techniques for removal of fibroids during an abdominal myomectomy are similar to those described for a laparoscopic
approach. Unidirectional barbed suture can be used, or an absorbable 2–0 or 0 Vicryl
®
(Ethicon, Cincinnati, OH) can also
be used.
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PEARLS AND PITFALLS
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POSTOPERATIVE CARE
Laparoscopic patients can often be discharged shortly after an observation period in the recovery room and further
managed on an outpatient basis. Those with an abdominal myomectomy can usually be discharged in 1 to 3 days.
Patients may try to conceive 3 months postoperatively.
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OUTCOMES
Compared to abdominal myomectomy, both laparoscopic myomectomy and robotic-assisted laparoscopic myomectomy are
associated with decreased blood loss, shorter length of hospital stay,
9
and lower incidence of adhesions at second look
laparoscopy.
10
Studies of reproductive outcomes directly comparing abdominal and laparoscopic myomectomy are lacking. A prospective
study of women undergoing laparoscopic myomectomy found that 70% who desired to conceive were successful.
11
Other
pregnancy outcomes and complications do not seem to differ in regards to route of myomectomy.
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COMPLICATIONS
Adhesion formation can occur, but a laparoscopic approach causes fewer and less severe adhesions as compared to an
open myomectomy.
Amount of blood loss is dependent on the size and number of incisions, but is significantly less than what is encountered in
an open myomectomy.
Retained fibroid fragments can lead to adhesion formation or parasitic myoma growth.
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KEY REFERENCES
1. Walker WJ, McDowell SJ. Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed
pregnancies. Am J Obstet Gynecol. 2006;195(5):1266–1277.
2. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials.
Eur J Obstet Gynecol Reprod Biol. 2009;145(1):14–21.
3. Pundir J, Pundir V, Walavalkar R, et al. Robotic-assisted laparoscopic vs abdominal and laparoscopic myomectomy:
Systematic review and meta-analysis. J Minim Invasive Gynecol. 2013;20(3):335–345.
4. Kashani BN, Centini G, Morelli SS, et al. Role of medical management for uterine leiomyomas. Best Pract Res Clin
Obstet Gynaecol. 2015;34:85–103.
5. Barbieri R. Give vasopressin to reduce bleeding in gynecologic surgery (editorial). Ob Gyn Management. 2010;22:12.
6. Pereira N, Buchanan TR, Wishall KM, et al. Electric morcellation-related reoperations after laparoscopic myomectomy
and nonmyomectomy procedures. J Minim Invasive Gynecol. 2015;22(2):163–176.
7. Uğur M, Turan C, Mungan T, et al. Laparoscopy for adhesion prevention following myomectomy. Int J Gynaecol Obstet.
1996;53(2):145–149.
8. Srouji SS, Kaser DJ, Gargiulo AR. Techniques for contained morcellation in gynecologic surgery. Fertil Steril.
2015;103(4):e34.
9. Barakat EE, Bedaiwy MA, Zimberg S, et al. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of
surgical outcomes. Obstet Gynecol. 2011;117(2 Pt 1):256–265.
10. Kubinova K, Mara M, Horak P, et al. Reproduction after myomectomy: comparison of patients with and without second-
look laparoscopy. Minim Invasive Ther Allied Technol. 2012;21(2):118–124.
11. Sizzi O, Rossetti A, Malzoni M, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim
Invasive Gynecol. 2007;14(4):453–462.
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4
Tubal
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Chapter 4.1
Tubal: Lysis of Adhesions
Travis W. M cCoy
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GENERAL PRINCIPLES
Definition
Tubal and/or ovarian adhesions can decrease fertility by limiting the interaction of the fallopian tube with the ovary, hindering
the ability of the tube to capture an egg (oocyte).
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